Starting simple with data exchange

Part 1: Ten states open health information exchanges to behavioral health providers who seek interoperable EHRs

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Computerized exchange of behavioral health information can be complicated by the need to comply with specific confidentiality requirements. Federal law, specifically CFR 42 part 2, requires not only that addiction treatment information be carefully protected, but that individuals have the right to allow or suppress instances of its disclosure. And, state requirements governing mental health and addiction data vary widely.

Yet at the same time, quality care depends on the sharing of such information with physical health providers as well as access by behavioral health providers to information about individuals’ physical or medical problems.

Recently launched federal and state efforts are trying to chip away at the legal and technological hurdles that stand in the way of better integrating and sharing behavioral- and physical health information.

“We don’t have a magic button for exchanging behavioral health data, but we are learning so much in the process of getting ready to mobilize data,” says Lee Stevens, a program manager for health information exchange (HIE) with the Office of the National Coordinator for Health Information Technology (ONC).

The ONC is coordinating attempts by HIE-development programs in Alabama, Florida, Kentucky, Michigan, Nebraska, and New Mexico to reach consensus on “putting the mechanisms in place that will allow that data to flow between unaffiliated providers in a secure way,” says Stevens.“We’re also finding ways that states can coordinate their consent requirements to actually exchange that data across state lines when it is necessary.”

In a separate initiative, five statewide HIE-development projects, each with a $600,000 grant from SAMHSA, are preparing the way for certain behavioral health information to be created in standard electronic form and viewed or exchanged online.

The National Council for Community Behavioral Healthcare, contracted to operate the program, is supervising and supporting information exchange to and from behavioral health settings in Kentucky, Illinois, Maine, Oklahoma and Rhode Island (Figure 1).

Despite the challenges posed by the need for confidentiality, “there are times when patients want that data to be moved,” says Stevens. “We’ve heard from numerous sources that there are plenty of patients that do want their data exchanged.” In that event, providers must know what’s necessary to exchange such data and develop an understanding of these evolving processes.

“Most everyone now really does consider this data to be completely locked up,” he says. “There’s not an understanding of what it would take to transmit this data if the patient chose to.”

To allow for practical exchange of such data, the behavioral health field would need to have, at minimum:

Agreement on, and development of, a list of behavioral health-oriented data elements to be shared.

The information technology in place to be able to communicate with other similarly equipped providers.

Behavioral health providers have unique needs

Much of the patient information now being shared electronically by primary-care doctors, medical specialists and acute-care facilities—medications, lab results, current physical illnesses, family history, and demographics—are also of value to behavioral health. Two SAMHSA grantee states operating HIE networks with extensive connections to medical providers—Maine and Rhode Island—are using their funds to extend access to this data to behavioral health providers.

• Develop and implement infrastructure to share behavioral and physical health records.• Review and make recommendations on elements specific to behavioral health to include in a Continuity-of-Care Document (CCD).• Work on processing consent directives in ways that comply with federal and state laws.• Incorporate lab results into infrastructure as structured data.• Support the use of electronic prescribing.

Source: The National Council

The electronic “envelope” by which EHR data elements pass from one computer system to another is a content and messaging standard called a Continuity of Care Document (CCD), created and maintained by the standards-development organization Health Level Seven, or HL7. Though the CCD allows the gathering and transmission of a wide range of medical data, “behavioral health data is a different thing,” says Gary Christensen, chief operating and information officer of the Rhode Island Quality Institute (RIQI), the state’s HIE operator. “So a standard CCD on its own won’t include much of the behavioral health record.”

One common omission is the bread and butter of behavioral health: the treatment plan. This plan documents physical conditions but also includes patient goals, objectives and the time frames and modalities for achieving them, says Michael Lardiere, LCSW, the National Council’s vice president for health information technology and strategic development. The current CCD standard does not facilitate that type of information, he says. Other shortcomings, noted by the HL7 behavioral health workgroup on which he is a member, include insufficient detail on patient problems and prescribing physicians.

The current orientation of the CCD’s problem list is based around medical conditions; it does not allow for the level of problem detail commonly required for behavioral health treatment, says Lardiere. And prescriber information doesn’t go far enough either, he adds. For a therapist working with a patient on medication who is not responding as hoped, it is often helpful to know the prescriber’s background or specialization.

“The prescribing pattern might be different for an internist than it is for a psychiatrist,” he suggests, noting that a therapist might place greater trust in prescriptions made by a psychiatrist versus those by an internist due to the psychiatrist’s specialized training.

It’s around those types of data needs that the five states with SAMHSA grants will be trying to build consensus. With the help of their behavioral health providers, these grantees expect to recommend data types for inclusion in the CCD and to share these recommendations nationwide, says Lardiere. He notes that the HL7 work group for behavioral health is comparing notes with an ONC work group that is examining CCD elements associated with continuity of care. Both groups, he says, are identifying information that should be shared during care transitions.

As some HIEs await the results of these standards-building efforts, others have done their best with what they had available. In 2006, a privately funded pilot in eastern Massachusetts—the North Berkshire e-Health Collaborative—was launched. It was able to get a clinical psychologist to participate and, for the 40 to 50 percent of that professional’s patients who gave their consent, specified sections of their records were shared with more than a dozen medical practices, says David Delano, who led that HIE development as then-CIO of its hub, North Adams Regional Hospital.

At the time, providers sought to balance usefulness against undue disclosure of sensitive patient information. A consensus formed around inclusion of some pieces of information relevant to the continuum of care—for example, medications, allergies, ICD-9 codes for mental health diagnoses—but exclusion of personalized information, such as the psychologist’s detailed narrative notes, Delano explains. “At the HIE level, it’s those coded elements that can be discovered, used electronically and incorporated into other electronic medical record systems.”

Connecting behavioral health to HIEs

The fundamental goal, of course, is to get behavioral health providers connected to networks and using technologies that allow them to send and tap into information securely and appropriately. In Rhode Island, more than 200,000 of the state’s 1 million people have signed up to permit the inclusion of their medical data in a network called currentcare.

To date, this network has processed more than 4 million health records from the state’s largest labs, eight hospitals and several physician practices. In Maine, a network called HealthInfoNet is already exchanging and making data available from 22 hospitals and more than 60 ambulatory-care organizations.

For both of these state initiatives, a major objective is to support the connection of as many behavioral health providers as possible. “What this grant allows us to do is really expand that (network availability) to the behavioral healthcare side, which we hadn’t done in the past,” says Shaun Alfreds, HealthInfoNet’s chief operating officer. “We’re laying the framework to begin to lower the barriers to true integration by making it so that information necessary to treat the patient is available at the time and point of care, no matter what kind of provider you care, no matter what specialty you’re providing.”

Having medical data for their patients is a big step for behavioral health professionals, who are “some of our most excited people about the kind of information that currentcare can provide them,” says Christensen. He predicts that it will be “incredibly helpful” for these providers to know “the basic information that they have zero access to today.”

The RIQI aims to support a “health home” program for the state’s Medicaid population by “creating the links between the physical provider and mental health provider as part of a continuous-care process,” he says. The IT linkage will help by creating the infrastructure to further those aims. Behavioral health organizations also will become additional venues for signing up patients, he predicts, while therapists will be able to see the available physical health information for individuals they are treating.

Direct protocol enables point-to-point EHR data swaps

A big emphasis in both the ONC and SAMHSA initiatives is the application of a secure and uncomplicated standard for CCD-powered, point-to-point exchanges between providers, a protocol that’s aptly called “Direct.” The protocol has spread quickly in the physical health sector, giving doctors a means of swapping EHR data without having to bear the technical and patient-confidentiality burdens of transmittal through a larger HIE.

“There’s no reason why the big, complicated HIE—which is all data available at all times to anyone who might need it—needs to get in the middle of two healthcare providers who have a clinical reason to share information,” says Christensen. According to the ONC’s Stevens, Direct is “the only technology that currently exists to move data between unaffiliated organizations in a secure way.”

For instance, a clinical psychologist reviewing HIE-accessed medication or lab data on a patient may have some questions for an internist also treating that same patient, and Direct would allow legally sound queries and exchanges from one EHR to another.

That would have been a boon to the Northern Berkshire pilot years ago, where the aim was “to at least give a high-level view of the record and the situational things that were going on” with a patient, says Delano, who now is a project director with the statewide HIE developer, the Massachusetts eHealth Collaborative. The Berkshire network gave enough of a peek into patient records for a provider to pick up a phone and inquire further about treatment supplied by a colleague; today that can be done electronically.

Expanding direct-enabled EHR system availability

In Rhode Island, where electronic records are widespread and medical providers are using dozens of different IT products, the challenge has been to get the Direct protocol added to existing EHRs and incorporated into new implementations, says Christensen. That same process will be expanded to the behavioral health side during the SAMHSA-funded one-year project. While eight vendors have made their EHR systems Direct-enabled for physical health providers, two vendors of behavioral health EHRs—Netsmart and ClaimTrak—will be doing the same for their customers.

The RIQI previously had selected those two vendors in an “environmental scan” of the industry as the furthest along in being able to produce a CCD and were, in Christensen’s words, “the best candidates for trying to create this interoperability.” All that held up the expansion was funding, which thanks to SAMHSA, is now in hand.

HealthInfoNet in Maine will supply Direct-enabled messaging services to 200 behavioral health providers around the state, staged in tiers, says Alfreds. In a survey, a handful of organizations had the EHRs needed to accomplish information exchange but many others did not have this capability. The five organizations with substantial EHR capabilities will get bi-directional connections to HealthInfoNet, while 20 organizations without such capability will get “view” access through a secure web portal to medical information on their patients.

While it’s clear that Direct-enabled EHRs don’t have the sophistication required to enable exchange of “specially protected” behavioral health information through large HIEs, it’s equally clear that for consenting individuals and their participating behavioral health providers, they’re a good place to start.

Next in Part II: Explaining a new CFR 42, Part 2-compliant EHR interchange protocol.